************NOTICE***********

REGARDING RELEASE OF INFORMATION

Dear Doctor and Staff:

As you know, I am seeking treatment with you as a result of an injury I sustained at work on the railroad. Because my injury occurred in connection with my railroad employment, it is important for you and your staff to have the following information:

THERE IS NO STATE WORKERS’ COMPENSATION COVERAGE FOR RAILROAD EMPLOYEES. Injuries on the railroad are covered by federal law which is not related in any fashion to State Workers’ Compensation laws. You do not need to, nor should you, fill out any Workers’ Compensation forms. Likewise, you should not send any information to the State Agency that administers Workers’ Compensation.

MEDICAL BILLS ARE NOT COVERED OR PAID BY WORKERS’ COMPENSATION INSURANCE. Because injuries are handled differently on the railroad than any other industry, Workers’ Compensation does not pay any of the bills.

PLEASE SUBMIT ALL BILLS TO MY HEALTH INSURANCE PROVIDER

DO NOT SUBMIT ANY BILLS TO THE RAILROAD WITHOUT MY EXPRESS CONSENT

DO NOT PROVIDE ANY INFORMATION ABOUT ME OR MY MEDICAL CONDITION OR CARE TO ANYONE EXCEPT MY SPOUSE OR FAMILY MEMBER, INCLUDING THE RAILROAD. The railroad may contact your office for information. I request that you and your staff not provide any information to the railroad. I will provide my employer with any information it may need.

I hope this information is helpful and will avoid any confusion or complications. Should you or your staff have any questions about the information I have provided with this letter, please give me a call.

Dated this ____ day of ____________, 20___.

Sincerely,

________________________________

Signature

Printed Name:____________________

Telephone No. ___________________